Periodontal conditions in insuiindependent diabetes meiiitus

B. Safkan-Seppala and J. Ainamo Department of Periodontology, University of Helsinki, Helsinki, Finland • :; :

B. Safkan-Seppala and J. Ainamo: Periodontal conditions in insulin-dependent diabetes mellitus. J Clin Periodontol 1992: 19: 24-29. Abstract. In the present invesfigation, the frequency and severity of periodontal ' disease was assessed in a group of 71 patients with a mean duration of 16.5 years of insulin-dependent diabetes mellitus (IDD). The diabetics, aged 17-63 years, were under treatment at the diabetic outpatient clinic of the III Department of Medicine, University Central Hospital of Helsinki and at two chnics of the Helsinki Health Centre. Based upon their long-term medical records, 44 individuals were assessed to have a poorly controlled insulin-dependent diabetes mellitus (PIDD). At baseline of the present study, the PIDD group had a mean blood glucose level of 11.8 mmol/1 and a mean glycosylated hemoglobin (HBA,) level of 10.7%. 27 subjects were classified as having a controlled insulin-dependent diabetes mellitus (CIDD). For each individual, site-specific recordings were made for the plaque index, gingival index, pocket depth, loss of attachment, bleeding after probing, gingival recession and radiographic loss of alveolar bone. Under similar plaque conditions, adult subjects with a long-term PIDD were found to have lost more approximal attachment and bone than subjects with a CIDD (P = 0.046, P = 0.019). These differences were not equally obvious when the subjects were classified according to the history of medical complications, such as retinopathies, neuropathies and nephropathies.

During the early insulin era, prior to 1922, several investigators assumed that all diabetics suffer from periodontal disease. Later on, high prevalences of periodontal disease among patients with relatively severe diabetes were found by Sandier & Stahl (1960), Finestone & Boorujy (1967), Cohen et al. (1970). Wolf (1977), Cianciola et al. (1982) and Ainamo et al. (1990). Benveniste et al. (1967) and Tervonen & Knuuttila (1986) reported that a controlled diabetic exhibits less severe periodontal disease than one whose disease is not under control. Also, Bay et al. (1974) observed a good response to periodontal treatment among young diabetic patients whose blood glucose levels had been successfully kept within normal limits. An interesting study made by Glavind et al. (1968) showed that patients with a diabetes history longer than 10 years had greater loss of periodontal structures than those with a history less than 10 years. Further, according to the same authors, the rate of periodontitis was the same up to 30 years but in the 34 to 40 year group, diabetics showed an increasing amount of periodontal breakdown compared with non-diabetics. This finding was in agreement

with those of Belting et al. (1964) and Sznajder et al. (1978). Wolf (1977) concluded that it was not until the ages of 40 to 60 that the difference in the loss of attachment began to approach statistical significance. With respect to the severity of periodontal disease, the chronologic age of the diabetics was claimed by Cianciola et al. (1982) to be more important than the duration of their diabetes. Lately, Bacic et al. (1988) and Hugoson et al. (1989) also found among 40-49-year-old long-duration diabetics significantly more tooth sites with probing depths > 6 mm and alveolar bone loss than in non-diabetics. Several investigators have suggested that diabetic children with poor metabolic control show a tendency towards higher gingival index scores than nondiabetics of the same age (Kjellinan et al. 1970, Gisle'n et al. 1980, Faulconbridge et al. 1981, Gusberti et al. 1983, Ervasfi et al. 1985, Leeper et al. 1985, Sandhoim et al. 1989). In a study perforrned by Ryiander et al. (1987), buccal and lingual plaque-free sites were found to show more gingival infiammation in young diabetics than in healthy control subjects. Recently, Hugoson et al. (1989) confirmed that insulin-dependent

Key words: periodontitis; cross-sectional study; insulin-dependent diabetes mellitus. Accepted for publication 25 October 1990

diabetics, irrespective of the duration of the disease, had a higher prevalence of sites with gingivitis than non-diabetics. Glavind et al. (1968) introduced the assumption that diabetics with retinal changes show greater loss ofattachment than diabetics with no complications of their diabetes. This assumption has been verified by Von Heinrich (1980), Ryiander et al. (1987), Bacic et al. (1988), and Willershausen-Zonnchen & Hamm (1988). Further, some case reports have suggested that rapid periodontal destruction may occur in adult humans with poorly controlled diabetes if these subjects have elevated blood glucose levels (Bartolucci & Parkes 1981, Ainamo et al. 1990). The purpose of this study was to compare the periodontal conditions of well-controlled (CIDD) and poorlycontrolled (PIDD) patients suffering from long duration insulin-dependent diabetes. Subjects and Methods

At the time of this study, 317 diabetics were being treated at the III Department of Medicine, University Central Hospital of Helsinki and at the Helsinki

Periodontal disease and diabetes trolled insulin-dependent diabetes (PIDD, Table 1). The medical history of these patients revealed previous problems with the control of their diabetes, such as ketosis, severe hyperglycemia, recurrent infections, ketoacidosis, glycosurea, diabetic coma or different stages of retinopathies, neuropathies and nephropathies. 27 individuals were classified as having a controlled insulindependent diabetes mellitus (CIDD, Table 1) with less complications from their diabetes. However, a!so supposed!y we!l-control!ed diabetics often had e!evated Ieve!s of HBA,. The mean blood g!ucose !eve! as we!l as the g!ycosy!ated hemog!obin values (HBAj) were significant!y higher (P = 0.011, P =

Health Centre. Of these subjects, 132 individuals had had insulin-dependent diabetes mellitus for at least 10 years. 36 patients were excluded from the study due to severe interfering complications of diabetes, such as blindness, or due to invo!vement in other research projects (WHO, insulin-pump investigation, etc.). The remaining 96 patients were invited to participate in the study. Of these diabetics, 9 had fu!! dentures and 16 diabetics were for various reasons unab!e to participate. Of the remaining 71 subjects, 44 individua!s had a mean blood glucose !eve! of 11.8 + 4.9 mmol/l (3c± S.D.) and were classified according to their long-term medical records to have a poorly con-

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Distribution of teeth

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Plaque index (Pll)

Recordings for plaque were made in the gingival third of the 4 tooth surfaces of each tooth according to the criteria of the Plaque Index system (Silness & Loe 1964). The % of tooth surfaces with plaque index scores > 1 was calculated. Individual mean scores as well as means representing buccal, lingual and two interproximal surfaces were recorded.

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The dental examination was performed by a specialist periodontist (B. S-S.), calibrated using an electronic periodontal probe with a standardized pressure of 20-25 g (Vine Valley Research, NY, USA). The examiner did not know the grouping of the subjects. Third molars were examined only when they replaced second molars. The examinations included recordings for the fol!owing parameters of al! teeth.

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Collection of data

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0.013) in the PIDD than in the CIDD group. The sex distribution in the PIDD group was 21 men and 23 females with 16 and 11, respectively, in the CIDD group. The subjects were also, based upon their medical records, classified according to the presence of established histopathoiogical complications of their long-standing insulin-dependent diabetes mellitus, such as retinopathy, nephropathy and neuropathy.

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PIDD CIDD Gingival index (Gl)

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For each individual, the presence of gingivitis was recorded for the buccal, lingual and two interproximal surfaces according to the criteria of the gingival index system (Loe 1967). The % of sites with GI scores > 1 was assessed.

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PIDD CIDD

Fig. 1, Mean proportion of remaining teeth in subjects having a poorly controlled insulindependent diabetes (PIDD, black bars) and in controlled insulin-dependent diabetics (CIDD, hatched bars).

Loss of attachment (LA)

The distance from the cemento-enamel junction to the bottom of the periodontal pocket was measured to the nearest mm. The LA measurements were made at 4 sites of each tooth except the molars. The molars were measured at the mesial, distal, 2 buccal and 2 lingua! sites. The mesial interproximal measurements were taken from the !ingua! and the distal from the buccal aspect of the dental arch

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Safkan-Seppdld & Ainamo

Pocket depth (PD)

The distance from the gingivai margin to the bottom of the periodontal pocket was measured with a WHO probe (tip diameter 0.5 mm). The pocket depth was measured at buccal, lingual and two interproximai sites of each tooth. Only pocket depths > 3 mm were recorded. Gingival recession (R)

Gingival recession was measured from the gingival margin (GM) to the cemento-enamel junction (CEJ) and recorded as the GM-CEJ distance. The GM-CEJ distance was measured at buccal, lingual and two interproximal sites of each tooth with gingival recessions > 1 mm.

subjects is presented in Fig. 1. A consistent tendency was observed: PIDD subjects seemed to have lost more teeth than the CIDD subjects. The tooth-specific histogram of the mean approximal attachment and bonelevel measurements clearly suggested that the PIDD patients had lost more attachment and more alveolar bone than the CIDD patients (Figs. 2, 3), This difference seemed evident, but did not reach statistical significance when all sites of the dentition were pooled for anaiysis. Statisticaiiy significant differences were found in the patterns of ioss of attachment {P

Periodontal conditions in insulin-dependent diabetes mellitus.

In the present investigation, the frequency and severity of periodontal disease was assessed in a group of 71 patients with a mean duration of 16.5 ye...
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